Monthly Archives: September 2015

Despite the best of intentions of most reputable papers and their editors, nonsense still gets published. Much of that nonsense pertains to theories of mental illness.

A perfect example of that was in my own local paper, the Hamilton Spectator on September 21. The Op Ed by a social worker was headed “Bad Behaviour is Bad Behaviour. Period.” The author, Alexander T. Polgar PhD, RSW, is a forensic social worker and public safety consultant. His PhD is in social work and RSW means that he is a registered social worker.

Dr Polgar was objecting to a recent report by the John Howard Society of Ontario which pointed out that many in prison in Ontario have untreated mental illness and that people often have to commit crimes in order to get mental health treatment. One of the authors of that report said that “Ontario must stop punishing people for their mental health issues and take ‘bold and immediate action’ to decriminalize mental illness.”

Now Dr Polgar objects to the fact that the primary premise of that report is that “mental illness is a medical problem” and he comments that this speaks “to the success with which bad behaviour has been and continues to be medicalized”. He goes on to say that “throughout history, those who behaved badly or strangely were considered to be possessed by demon spirits and the solution was to ‘beat the devil out of them’”.

He says, we no longer beat them in Western cultures but we do punish them in a variety of ways including incarceration. He then adds that the medical model of madness continues to compete with the demon-possessed causes of bad behaviour. Freud, he said began to change that with a focus on family dynamics, social conditions and various relational issues. That gave rise to psychotherapy, counselling, behaviour modification and family therapy. Not surprisingly, he cites Thomas Szasz and RD Laing.

But, the resistance to Freud, Szasz and Laing are the result of two problems – the human proclivity to abdicate familial and social responsibility for troubled children who become dysfunctional adults and a profit driven pharmaceutical industry who can provide a solution that justifies the abdication of reponsibility.

He concludes his piece by saying that “we cannot and should not tolerate from anyone bad behaviour. This includes bad behaviour from those we currently label as the mentally ill.”

And, finally “the best place to modify these socially unacceptable behaviours contrary to the views of the above cited report, is in correctional institutions and in community based correctional programs provided by behaviourally trained personnel far better resourced and equipped than they are now.”

Unfortunately I can’t give you the link to the article so you can read it for yourself as it is one of the very few articles that the paper did not put online. They may have read my letter to the editor with copies to the senior editors which they did not publish.

But, who is Dr Polgar? Well, interestingly enough, he has been prosecuted by the College of Psychologists of Ontario (CPO) for the unauthorized practice of psychology. In 2006, the CPO applied to the Ontario Superior Court of Justice for an order to desist. It was alleged that “he held himself out as a person who is qualified to practice in Ontario as a psychologist or in a specialty of psychology. The Application also related to allegations that he performed the controlled act of communication of a diagnosis in the circumstances described in the Regulated Health Professions Act, without being a member authorized by a health profession act to perform the controlled act.”

The case did not get to court as Dr Polgar agreed that “Without any admission that he has done so in the past, Polgar agrees that he will refrain from communicating in any report to any client or other person, any diagnosis, meaning any statement identifying, as the cause of a person’s symptoms, a neuropsychological disorder or a psychologically-based psychotic, neurotic, or personality disorder. It shall not be considered a violation of this agreement for Polgar to make and communicate social work diagnoses as that expression is defined by the OCSWSSW.” (the College of Social Workers)

Russia currently has Mr. Putin, the Macho Man. He loves nothing more than to bare his chest, let his pectorals ripple, to hunt large animals, display his strength and resolve. He feels he embodies his country, and many of his countrymen feel the same.

This is dangerous.

Then we had George W. Bush. As I watch Donald Trump I am gaining some sympathy for George. George wasn’t smart, but he tried. When he mangled our common language, when his words issued from his mouth in stumbling contradictions and malapropisms, one felt he was trying to say something intelligent and reasonable but he just didn’t have the skill or the mastery of language. When he talked in black and white terms, and borrowed his language from young adult fiction (“evildoers” for example), I felt he would be more nuanced if he could. When he backed stupid policies I felt he wouldn’t do this if he actually grasped the probable consequences of them. He probably did actually believe one could just invade Iraq, destabilize the Middle East and set them all on a path to democracy.

He was dangerous.

And now we have Donald Trump. His use of language is even less sophisticated than that of George W. Bush, but I get the feeling it is a pose, a performance. A performance by a very narcissistic man with no scruples. None whatsoever. Willing to play on every base fear of a semi-educated American public. Appealing to the adolescent super-hero fantasy that plays, occasionally, in everybody’s mind. Willing to play on fears, prejudices, pride, and myth. I think he loves the idea of being president like he loves the idea of having his name on large impressive buildings.

The pundits don’t think he can be elected. They hope he will crash and burn. But he might not.

He is very dangerous.

So (God help us) we may have Putin and Trump at their respective helms in the same decade.

This will be extremely dangerous.

If Canada is to ameliorate this danger to any degree we must have a leader who could do so. A Mike Pearson maybe. Not Mr. Harper. Mr. Harper is smarter than Trump or Bush, and more civilized than Mr. Putin, but his instinct is boldness, brashness, assertion of power and control; he would like to be emperor. He is not dangerous within our parliamentary democracy, but should he find himself sitting at a table with Trump and Putin, could he avert disaster? Or would he too thump his chest and get us all killed?

Mulcair and Trudeau have not been tested. But either of them, at that table with Trump and Putin, is more likely than Harper, I think, to suggest a peaceful solution, to negotiate, to mediate, to avert disaster, to be a second Mike Pearson.

As much as we are sure Schizophrenia is a neurobiological illness, we remain unsure if it is a spectrum of disorders, or several different illnesses with different pathways to a similar syndrome. As Marvin pointed out recently, more than a century ago, Eugene Bleuler, who coined the term schizophrenia, thought of this illness as “the schizophrenias”, a spectrum of disorders.

In fully understanding and dissecting out the actual causes, both necessary and contributory, and the actual pathogenesis of the severe mental illnesses, we are decades behind our understanding of viral illnesses, heart disease, and cancer. There are reasons for this beyond the fact that the brain is a more complicated organ than the heart.

Emil Kraeplin, who, with Dr. Alzheimer, first described the disease we have come to know as Alzheimers, also studied the young people with persistent psychotic illness in his hospital. Relying on observations of behaviour he very accurately described the symptoms of what he called Dementia Praecox, and the course of the illness, as objectively as possible.

Unfortunately his observations were lost for many years under the onslaught of psychoanalysis and other mind-based theories, including Bleuler’s. In effect the objective observations of the behaviour and speech of schizophrenic patients was overshadowed by interpretations of these behaviours.

For example, some people with schizophrenia speak in a particular monotone, their speech devoid of many of the nuances of non-textual language (non-verbal) language that most of us use to modify, clarify, or even negate our actual text. Kraeplin described this. But Bleuler interpreted this as “blunted affect”. That is, he extrapolated from the observation of a communication difficulty to posit an “underlying emotional problem”.

Similarly Kraeplin described the way some of his patients, in mid sentence, might switch to a different apparently unrelated topic. Bleuler, logically but prematurely, extrapolated this to mean something was wrong with the way these patients formed their thinking, that their associations from one thought to another were differently based.

So for years after this, in the diagnosis of schizophrenia, we have clinicians looking for “blunted affect” and “loosened associations,” rather than, “a problem in contextual information processing” or “abnormal patterns of speech and semantic construction.”

A common and defining symptom of schizophrenia is the presence of delusional thinking. Yet some delusional people have an observable problem with contextual information processing and some don’t.

The second evolution that inhibited the development of our understanding of schizophrenia was, paradoxically, the accidental discovery of a medication that worked: chlorpromazine. Followed by other medications. Again, a natural line of inquiry and understanding opened up, this time extrapolating from the chemistry of the drug that works, back to the cause of the illness, and interest in more carefully defining, by observation, the symptoms of the illness(es) waned.

So in genetic research we are left trying to find a correlation between genetic differences and very poor, vague, delineations of syndromes.

It would be not dissimilar to seeking the genetic differences that lead to fever, fatigue, nausea, and sore joints.

It could be of immense help if we had better ways of defining, by observation, the specific pathways to the diagnosis of schizophrenia.

If you have a family member who suffers from schizophrenia, schizoaffective disorder or psychosis not otherwise specified, we would like to enlist your help in doing this by clicking on the following link and filling in the questionnaire. This will be anonymous and only take a few minutes. We are testing a hypothesis of five pathways to these diagnoses. If none of the descriptions fits your situation, please describe this, or the differences from the examples given.

If we can better define the different illnesses and pathways that result in a diagnosis of schizophrenia, we may be better able to find the underlying causes. We would appreciate your help in answering this simple questionnaire below.

We are all guilty of using language badly, without clarity of definition. We talk of concepts as if they are physical entities. Words that denote complex relationships, even systems of abstract thought, can become epithets, mindless accusations. Over time some words we use take on meaning quite opposite to their original meaning. Usually, behind every shift in meaning lies the politics of power and ingrained attitudes.

What are we talking about when we use terms like medical model, disease model, biological model, bio-psycho-social model, holistic model?

Maybe that is not the real question. Because often when people use those terms they are really expressing attitudes and power positions, or railing against someone else’s attitude and power position.

So instead I will ask the question, what do these terms in their original form and intent mean?

Let’s take the “medical model”. This really speaks of the relationship between doctor/healer and patient/sufferer. It has been pointed out that this particular social contract predates the disease model by many centuries, and that in most or all cultures someone is assigned, earns and accepts the role of “doctor/healer/shaman”. It speaks of a set of guidelines, expectations regarding this relationship, a set of responsibilities and privileges assigned to each (doctor and patient) within the unspoken but generally well known and accepted contract. It is the contract you want your doctor to fulfill when you go to her as a patient with chest pain or a psychotic family member. The doctor’s side of the contract is succinctly explained in the Hippocratic oath, though all the nuances of this contract could fill a large book.

We know that for chronic illness the medical model requires adjustment: the doctor takes a little less responsibility, the patient more, and allied health professionals, and family members share the burden and some of the responsibility.

We also know that for some situations the same medical model that works so well for acute illness can be dangerous when applied to something like addictions. For when the doctor reaches for her prescription pad, she is fulfilling her social contract with this patient to do her “utmost to relieve suffering” – but simple relief of suffering may not bode well for an addict, no matter how much he or she is demanding it.

Physicians in this part of the world have adopted the “disease model”, a scientific and systematic approach to their patient’s illnesses. It is a model, as described before, that implies cause and effect, determined by evidence and science, and an attempt to alter or correct the primary or necessary cause of the distress (e.g. bacteria) and to alleviate symptoms and suffering by understanding their pathogenesis, their mechanisms. This is not all biological in nature: the prescription of antibiotics to kill the germs (biology, reductionistic), the prescription of aspirin to quell the fever (symptom relief from evidence and understanding the mechanism of fever), the advice of bed rest and fluids (holistic health) and the letter excusing someone from work for a few days (definitely a social intervention), to say nothing of reassurance and explanation (cognitive/psychological intervention).

Those who rail against the “medical model” are almost always railing against not the concepts or methodologies of modern medicine but about the status and power of the doctor.

A biological model is reductionistic. It is a focus on biological impairments, mechanisms and pathways that lead to symptoms and distress.

The bio-psycho-social model (which has been called the three legged stool) attempts to add and understand the influences of cognition/emotion and social environment to the problem at hand.

Fair enough, but in practice we want to find, if it exists, the necessary cause of the distress, the illness, the disease. This could be biological. It could be a bad marriage. The bio-psycho-social model reminds us of this, and that all spheres may be playing a role.

Though in truth I would like it to be renamed the bio-socio-psychological model, because it seems clear to me, in my amateur studies of ethnology, evolution, societies, social groups, and human behaviour, that we are primarily biological beings, driven by instinct and biological mechanisms, that secondarily we are social beings, our behaviours and thoughts modified by the social imperatives of our cultures, societies, families, and only lastly are we psychological beings, with our behaviour, to some small extent, driven by thought, reasoning, logic, compassion, understanding. Usually our thoughts are used to simply rationalize or justify those behaviours driven by biology and social imperatives.

I must confess that I’m not really sure what that means other than that it has been an accusation leveled at me. One of my advocacy colleagues told me recently of a conversation she had with a member of the mental health bureaucracy and my name came up. The bureaucrat said he read me and that I was a controversial writer (I try) but that I was a reductionist. I wasn’t sure if that was a complement or an insult.

What does our being accused of being reductionists mean? Richard Dawkins, in The Blind Watchmaker (1996) said “Reductionism is one of those things, like sin, that is only mentioned by people who are against it.”This was quoted in Reductionistic and Holistic Science by Ferric C Fang, the editor in chief of the journal Infection and Immunity.

The abstract for this paper states:

“A reductionistic approach to science, epitomized by molecular biology, is often contrasted with the holistic approach of systems biology. However, molecular biology and systems biology are actually interdependent and complementary ways in which to study and make sense of complex phenomena.”

And then the paper goes on to say:

“Few scientists will voluntarily characterize their work as reductionistic. Yet, reductionism is at the philosophical heart of the molecular biology revolution. Holistic science, the opposite of reductionistic science, has also acquired a bad name, perhaps due to an unfortunate association of the word “holistic” with new age pseudoscience.”

The author substitutes system biology for holistic biology because it lacks the pejorative nature of holistic. And I don’t want to try to give a precis of this paper but simply to say that molecular biology is an example of the triumph of reductionism. But holism goes back to Aristotle and the two are not mutually exclusive. Again, the author states that:

“Each approach has its limitations. Reductionism may prevent scientists from recognizing important relationships……..Holism, on the other hand, is inherently more challenging due to the complexity of living organisms in their environment.” And, “When fecklessly performed, systems biology may merely describe phenomena without providing explanation or mechanistic insight or create virtual models that lack biological relevance”.

Furthermore, “It is difficult to imagine how a number of important scientific discoveries could have been made by any method other than a reductionistic approach.” However, the author points out that the “reductionistic and holistic methodological approaches have been coexisting and thriving for centuries. One can argue that Darwin’s theory of evolution represents an early example in which many reductionist observations on finches and domesticated pigeons were synthesized into a system that unified all of biology……….Nevertheless, there is no denying the revolutionary impact of holistic thinking on the field, both in calling attention to situations in which reductionistic approaches have been deficient and in the generation of new experimental approaches for the analysis of complex systems .”

There are many other sources on the reductionist/holistic dichotomy and you can peruse them if you wish. It is only through reductionistic scientific enquiry that we may find a specific and necessary cause of a problem though many other factors contribute. But, it is also wise to have a holistic perspective.

There is no either/or in our search for answers and explanations and to abide by one methodology while ignoring others, is stupid and narrow minded. So, thinking, as some seem to do, that they can dismiss my views or those of Ms Inman as reductionist serves absolutely no purpose whatsoever. It says far more of them than it does of us.

Anyone who is honestly seeking truth needs to be open to reasoned arguments and to the unbiased evaluation of fact.

Next On Models, Concepts, Power, and Politics – Part II by Dr David Laing Dawson